Utilization Review Clinician

About the Role

WellSky is seeking a Utilization Review Clinician to join our team. This remote role requires working Thursday to Sunday, 6AM to 5PM OR 7AM to 6PM Central time. The primary responsibility is to review medical records to determine medical necessity, manage admissions, and ensure timely post-discharge follow-ups to prevent readmissions. You will assess the appropriateness of post-acute services using clinical guidelines and collaborate with healthcare providers to improve health outcomes.

Key Responsibilities

• Conduct prior authorization reviews and/or continued stay reviews for post-acute care services by applying clinical guidelines and escalating cases to medical directors as needed.
• Approve services in compliance with health plan guidelines, contractual agreements, and medical necessity criteria.
• Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care and seamless care transitions.
• Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth.
• Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes.
• Support all payer programs and initiatives related to the post-acute space.
• Make benefit determinations about appropriate levels of care using clinical guidelines.
• Coordinate benefits and transitions between various areas of care.
• Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively.
• Perform other job duties as assigned.

Required Qualifications

• Bachelor's degree or equivalent work experience.
• 4-6 years of clinical nursing or therapy experience.
• Active RN, OT, or PT license.

Preferred Qualifications

• 1-2 years' experience in utilization review, case management and/or managed care regulations.
• Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes.

Job Expectations

• Willing to travel up to 30% based on business needs.
• Willing to work additional or irregular hours as needed.
• Must work in accordance with applicable security policies and procedures to safeguard company and client information.
• Must be able to sit and view a computer screen for extended periods of time.

About WellSky

WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky, you can make a difference.

WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace.

Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates.

Benefits at WellSky

• Excellent medical with Rx, dental, and vision benefits
• Mental Health support through EAP
• Generous paid time off, plus 13 paid holidays
• 100% vested 401(K) retirement plans
• Educational assistance up to $2500 per year

Key skills/competency

• Utilization Review
• Medical Necessity
• Clinical Nursing
• Case Management
• Prior Authorization
• Health Plan Guidelines
• Care Transitions
• Clinical Guidelines
• Managed Care
• RN/OT/PT License